A Naturopathic Approach
by Dr. Amanda Ng, ND
Gastrointestinal reflux disease (GERD) is the backwards flow of stomach contents into the esophagus, often referred to as “heartburn” or “acid reflux.” GERD most commonly results from increased abdominal pressure or a dysfunction of the lower esophageal sphincter (LES), a bundle of muscles located at the end of the esophagus where it meets the stomach. GERD may arise with increased transient relaxation of the LES or reduced LES muscle tone. GERD may also present in those who have a hiatal hernia where the upper portion of the stomach protrudes into the chest cavity through an opening of the diaphragm.
The presentation of GERD can vary from person to person, but the most common symptoms include chest pain (also known as heartburn), acid or food regurgitation, difficulty swallowing, and indigestion such as bloating and nausea. These symptoms are often present after meals or when lying down. Other less common GERD-related symptoms include laryngitis, cough, asthma, dental erosions, and recurrent pneumonitis which may only manifest in cases of chronic, long-standing GERD.Most often, GERD results in changes in the esophageal mucosa due to the erosive properties of gastric acid, which can lead to further progression of disease and possible complications such as Barrett’s esophagus and esophageal bleeding if left untreated.
In North America, GERD is the most common diagnosis of all gastrointestinal complaints. In Canada, an average of 5 million people, pregnant women and children included, experience GERD-related symptoms at least once per week. The diagnosis of GERD is primarily made on the basis of symptoms. If patients present with typical symptoms of heartburn and acid regurgitation, treatment measures are often prescribed without the need of investigative tests. For patients with frequently recurring symptoms over a long period of time and also present with weight loss, vomiting, difficulty swallowing, or evidence of gastrointestinal bleeding, diagnostic testing is often warranted. Specific diagnostic tests include (but are not limited to) upper gastrointestinal endoscopy, endoscopic biopsies, esophageal barium radiography, and esophageal manometry. These tests can definitively evaluate acid reflux, esophageal lesions, and LES transient relaxation time and muscle tone.
Currently, proton-pump inhibitors (PPIs), are considered first-line therapy for anyone presenting with GERD-related symptoms and has even become a method of diagnosis. PPIs block the gastric acid pump of the cells in the stomach, resulting in diminished release of hydrochloric acid into the stomach. In comparison to other conventional treatments, PPIs have had the best outcomes with providing complete relief in the symptoms of GERD and long-term healing of esophageal erosions. PPIs have also been used to effectively treat more extensive conditions like Barrett’s esophagus and Zollinger-Ellison syndrome. Although prescribed with great effect, it has been found that PPI therapy can negatively affect intestinal microflora composition, predisposing patients to H. pylori and C. difficile infection, and can increase the risk of developing gastrointestinal tumours.
Less-commonly used medications are prokinetics and histamine H2 receptor antagonists. Prokinetics increase esophageal and gastric peristalsis, which help to strengthen the LES and cause the contents of the stomach to empty faster. Histamine H2 receptor antagonists function similarly to PPIs, but they reduce hydrochloric acid release in the stomach however via a different mechanism. These two families of medication are not as commonly prescribed, due to their slower onset of action and short-term effects, and have not shown to be as effective as PPIs in healing esophageal erosions.
Diet and Lifestyle
In the naturopathic treatment of GERD, it is important to address and remove the obstacles to cure. Since GERD is a disease of the gastrointestinal system, diet and lifestyle modifications should be made. To reduce the pressure on the LES, it is recommended to eat small, frequent meals and to wait 2–3 hours before lying down after a meal to allow for more efficient gastric emptying and overall digestion. It is also advised to limit or avoid certain foods that predispose to reflux by irritating the esophagus and relaxing the LES. These foods include caffeine, alcohol, vinegar, tomatoes, citrus, onions, chocolate, carbonated drinks, spicy foods, and mint. Smokers should be encouraged to quit smoking as it increases acid production, decreases the LES pressure, and predisposes to esophageal cancer. To reduce reflux symptoms throughout the night, it is often helpful to sleep with the upper body elevated by raising the head of the bed with either a foam wedge or block.
Demulcent, or mucilaginous, botanicals are traditionally used as mucoprotection of the esophageal mucosa, both to soothe irritated tissues and promote healing. Such demulcent botanical include licorice (Glycyrrihza glabra), marshmallow (Althea officinalis), and slippery elm (Ulmus fulva). By providing a physical barrier to the mucosa and by stimulating protective mucin production, demulcent herbs have been shown to notably decrease the intensity of symptoms such as upper abdominal fullness and epigastric pain. Studies have also found that demulcent herbs exhibit significant ulcer-healing properties in comparison to placebo or control after only eight weeks of treatment. It is important to note, when using licorice long-term, that it is preferable to use the deglycyrrhizinated form (also known as DGL), to prevent the potential side effects of raising blood pressure. Also note that marshmallow and slippery elm should not be taken at the same time as other medication, as they can decrease their absorption and impact their efficacy.
Like their demulcent counterparts, anti-inflammatory botanicals are also used to provide GERD symptom relief by promoting healing of irritated mucosa. Botanicals specific to GERD treatment include chamomile (Matricaria recutita), caraway (Carum carvi), milk thistle (Silybum marianum), lemon balm (Melissa officinalis), peppermint (Mentha piperita), and greater celandine (Chelidonium majus). These herbs have been shown to improve gastric motility, protect against the development of ulcers with decreasing acid production, increase mucin production, and increase anti-inflammatory cytokines. Although such herbs can improve gastric motility, they have not been shown to necessarily decrease gastric emptying time.
Melatonin is a naturally occurring hormone produced in the brain and gastrointestinal tract. From the pineal gland in the brain, melatonin acts as an endocrine hormone and is involved in regulating circadian rhythms, specifically the sleep-wake cycle. Within the gastrointestinal system, melatonin is involved in several mechanisms pertaining to the regulation of gastric-acid secretion, maintenance of structural integrity, and regulation of inflammation. Studies found that the treatment of GERD with melatonin resulted in an increase in serum gastrin levels, an increase in LES pressure, and a decrease in transient LES relaxation duration. Therefore, melatonin protects the esophagus by minimizing contact with gastric refluxate. Through its antioxidant properties, melatonin has been shown to protect gastric mucosa from free-radical damage, nonsteroidal anti-inflammatory drugs (NSAIDs), and other gastrotoxic agents by increasing circulation to the esophageal mucosa and stimulating the production of anti-inflammatory cytokines.
Choline is as essential nutrient for humans, and it is necessary for the structural integrity and signaling function of all cells. Choline is also used for neurotransmission, where choline combines with another compound called acetyl CoA, forming acetylcholine, a neurotransmitter of muscle activation. Since phosphatidylcholine is a precursor to acetylcholine, it has been used for the purpose of strengthening and toning LES-muscle contraction. Choline can be found in foods such as eggs and meats including poultry and fish. Higher doses of choline are needed for the treatment of GERD; therefore, supplementation with phosphatidylcholine is the best option in comparison to food sources.
With the numerous natural treatment options available, GERD is relatively uncomplicated and can be treated effectively at the onset of symptoms. If left untreated, GERD can progress into more serious and complicated conditions which may require more intensive interventions, such as surgery. Often, using a number of treatments that work via different mechanisms often yield the best outcomes whether you chose conventional treatment, naturopathic treatment, or both. Keep in mind that it is important to work with a naturopathic doctor when it comes to determining the correct course of treatment for you.